Finishing my book then having a good lie down – on the couch

Greetings all,

Well, I am very happy to say I wrote the final words of my new book “How Shrinks Think” yesterday (editors changes pending). The last word I wrote was ‘psychiatry’. The last topic I wrote about was psychiatry and social media. Who would have thought that this Facebook avoidee and Twitter ignorant person a year ago would now be embracing this great means of global communication!

It is timely for me to reflect on this change in my learning and outlook. That’s because I don’t think I would have ever finished my book (editors changes pending) if I didn’t receive all the help, support, encouragement and opportunity I have been fortunate to experience in the Twitterverse this year.

Some of my friends and colleagues in my life know I have been writing a book since August 2013. Many don’t. It does feel embarrassing I suppose to announce where ever you go that you will be an author someday. So, in the main I didn’t. But on the rare occasion that I did, people seemed generally interested. They were interested to know what I had written about and incredulous that I could be relatively easy in this era of self-publishing. But largely, I have written the book just for me. I don’t know how it’s going to be received, but regardless, I will continue to remember that.

In all sorts of ways the interrelationship between my experiences on social media and my writing journey have been closer than I would have imagined. I began to ‘play’ with the concept of writing about modern day psychiatry from the ‘inside’ on January 1 2014. I started my blog “How Shrinks Think” to sort out my own thoughts as well as gauge others impressions of what I had to say. I was scary at first but then a whole lot of fun. Then I gained the courage to use my voice as blogger and writer of “How Shrinks Think” in order to enter the world of campaign building. I was very involved in @AHPRAaction in May, and then wrote about the federal government proposed Medicare Co-payment and the effect it would have on those with severe mental illness. This propelled me into re-connecting with colleagues from the past, particularly from my AMA days, including Mukesh Haikerwal, and Amit Vohra. Opportunities arose from this including the privilege of being a speaker at the inaugural AMA(Vic) DiT conference.

I also discovered the talent and experience other doctors in Australia had when it came to writing. Although we have never met face to face, I consider Edwin Kruys in Queensland and Jacquie Garton-Smith in Western Australia to have really inspired me to keep writing and ultimately ending the journey that is the first draft of a book. I was fortunate enough to have some blog posts picked up by Croakey, and managed to connect with psychiatrists in Australia and around the world.

It is no coincidence that I will launch my book at @SoMebythesea on November 15^th 2014. I am organising this workshop amongst incredible people, many  I would never have met were it not for Twitter. It is amazing that virtually all of the organisation and promotion for @SoMebythesea has occurred via the amazing network opportunities of social media. Now I have Dionne Kasian-Lew, Marie Bismark, Mary Freer and Jen Morris coming along to speak at @Somebythesea. All people I have met via networking.

Of course, I have not forgotten my friends from the beginning and pre SoMe. Some are also growing and expanding their social media presence, like the sleep guru David Cunnington. Brad Mckay has been a great mate all along and a wonderful mentor for me in this new foray. My journey did begin with Andrew Griffiths and Kylie Bartlett, and I will always be grateful for their teachings and guidance. And all my friends who have been there, offering advice and encouragement.

So, the next 6 weeks are now in the hands of my editor, Roy Mazucco, and designer, Carly Goodwin. Incredible to believe but if all goes to plan, I will have my book in my hand in 6 weeks. May need to see a psychiatrist to process it all.  

Shrinks and Social Media

I don’t ever remember learning about social media at medical school back in the '90s. Social media was reading the newspaper or a magazine before uni started. In the olden days, merely 20 years ago, we had no idea the www was coming.  Dr Google was somewhere in the lecture theatre but we didn’t recognise him/her, and we couldn’t imagine that there would be communal platforms like Facebook around to unite strangers and label them friends.

Lecturers teaching ethics in medicine did not fathom a world where doctors would live within social media, and have to work their way through the twists and turns of setting up and maintaining Facebook personal pages, doing their best not to be found on social media by their patients, yet really wanting to share photos of recent holidays, and remain in touch with colleagues.They certainly wouldn't have envisaged doctors embracing socila media as an effective means of building communities, promoting evidenced based helath messages and influencing for change. 

Regulatory bodies such as AHPRA and professional associations such as the AMA have tried to keep up with the growing trends of what was considered a fad and considered absolutely not relevant to professionals, certainly doctors, but then had to begrudgingly accepted social media as something here to stay. Unfortunately the regulatory bodies, not the medical profession have advocated for the way social media should be used in medicine, and many doctors remain unaware that they need to know more about social media in medicine.

More and more, doctors want to influence debates on health matters, and nowhere is this more real than in psychiatry and mental illness. In 2014 we must realise that stigma is rife and campaigns such as ’@RUOKday’ and days dedicated to suicide prevention are popular because there still exists a fundamental belief that to be depressed is weak and something to suffer in silence. Large NGO’s with stacks of cash  have departments that run social media campaigns, driving their messages home, influencing the debate and keeping the radar on the topics. But what about doctors? Why do we believe others can pledge our plights and we can be taken as read, without being read, that we support or refute an argument or counterargument without making our own unique and collective point of view known? How do doctors, particularly psychiatrsts feel about campaigns such as @RUOKday, and what are they saying about it?

In Australia, the ABC is running a campaign called 'Mental As' to coinicide with national Mental Health week in October 2014. Great to use high profile celebrities to 'raise awareness', but what does a psychiatrist feel about a campaign being labelled "Mental As?" How do psychiatrists feel about raising awareness for a most valuable area of health, yet with limited funding to provide care when patients seek help?  How do psychiatrists feel about being labelled as those that treat 'mental patients, a most derogatory and stigma enhancing term. Isn't that where psychiatrists can have a say? In summary, advocacy about mental illness on social media is one sided, lacking a robust evidence base and not informed and influenced by experts in the field - psychiatrists themselves.

In the last 5 years it is pleasing to see medical colleges such as RANZCP and RACGP join social media, tweet regularly and highlight very important policy decisions they are making regarding such critical issues as the mental health issues facing asylum seekers and offshore detainees. In recent times we have seen doctors unite over issues they are passionate about such as #AHPRAaction, #ScrapTheCap and #CoPayNoWay. Because the fact is this. Social media is not for posting what you ate for lunch or where you spent your holidays. Social media is for connecting, uniting and advocating as a mass of people from so many walks of life that would never have been able to come together so quickly in any other way. Campaigns on social media work quickly, they pack a punch and they influence.

I write as a novice to social media, coming on board in January 2014 as a naysayer and critic. It was because I didn’t know about this side of social media. I learnt from other professional bodies, dipped my toes in the twitter universe and discovered to my amazement there were people I could find and follow who felt like me. People who admired what I did and followed me back. I quickly joined an amazing campaign called #AHPRAaction and stood up to our regulatory body to defend our rights in the context of social media. Four months after I opened my twitter account. Now I blog regularly, have a company Facebook page, tidied up my LinkedIn profile, set up a psychiatrist’s and registrars group on Linkedin (PARA) which is gaining membership, and have almost finished my first book.

And what about me as a doctor, passionate about psychiatry, and with my experience as a writer and learning the ropes about being a shrink? Well, now I have a voice and a brand. I have stepped forward and claimed my identity that is authentic to me, before others can post about who they think I am. I have bought my domain name www.drhelenschultz.com, and claimed the @Drhelenschultz  twitter handle before somebody else does and pretends to be me. Not a narcissistic thing to do, but a sensible thing to do, as the real estate space in social media gets clogged, people find new ways to influence and may wrongly do so by purporting to be somebody else. And because I want to guarantee my future both in the business and medical world as well as the social media world. The two are intertwined. I love the feeling that I can write what I think and own it, and others can truly decide whether they admire me or not because they know the real me.

As for psychiatry, I will continue to have a presence and a voice on social media, finish my book “How Shrinks Think” and be a thought leader when it comes to our treatment of those with mental illness, and what we can all do better. I’ll stand aside NGO’s and colleges as somebody who works within the system and has a right to have a say. That say will be shouted on social. 


Dr Helen Schultz is a consultant psychiatrist based in Melbourne, Australia. She is also founder of CPD Formulations, a medical education company that creates medical education programs written for doctors by doctors. Her new workshop is called @SoMebythesea, to be held on 15th November 2014, in Torquay, Victoria. It will be the inaugural social media workshop for the medical profession. 

Healing the scars from registrar training

Greetings all, 

The title bears no need for explanation. We all know what I am talking about. Those horrific nights on call we thought would never end, the continual feelings of being out of our depth. The feeling of total inadequacy and a longing to go home.

Now I am a consultant psychiatrist and have run away again from reality to work on the last revisions on my first ever book, How Shrinks Think. Not bad given I have wanted to be a writer since I was 12 and I am now 46. Still, I have built up more to write about and feel more confident about what I want to say. 

My warts and all account of psychiatry from my perspective began taking shape about a year ago. The first draft was finished in about a month. 1000 words a day for 30 days. Then I stopped, struck with fear because I presumed I would be criticised by my peers for saying what I wanted to say about how psychiatry is according to me the most exciting speciality of medicine, but also the one that is most controversial and misunderstood. So it sat with my editor, Roy, until about 2 months ago. 

Now, I feel I have confidence, so have continued in earnest to achieve my deadline for my book launch of 15th November 2014.

As part of all of this, and to stop myself being distracted by my pantry that needs cleaning, weeds that need removing from the garden, the need to concoct the most difficult recipe from Australian Women's weekly all-time favourites cookbook when home alone, pay attention to the cat, do my nails, organise my home office and watch crap on Foxtel, I have started getting into these 'writer in residence’ weekends where I simply run away to a beautiful hotel, languish by the fire and look all mysterious with my laptop. I love it when the check in staff ask me if I am on a holiday, and I can quickly retort, oh no, I am a WRITER and here to work. I'm sure they laugh as I drag my luggage, my snacks and my books up to my hotel room. 

So here I am, at writers retreat number 2.

I have checked into the newest Art series hotel, The Schaller, in Bendigo. Not just in Bendigo but on the grounds of the Bendigo hospital. Not only on the grounds of the Bendigo hospital but where the nurses accommodation used to be. Not only where the nurse’s accommodation used to be  but where I stayed for 6 months (3 as a medical student and 3 as a psychiatry registrar). Ok. Big breath. This has to be for a reason. The walls ain’t talking because they are all new, but hey if they could, they’d remember me as a scared medical student, homesick, much older than my peers so didn't fit in, then returning as a psychiatry registrar for 3 months. I remember my great mate Carlos, another psych registrar who walked in after our first day on rotation here in psych to say, “lets' celebrate, it's only 11 weeks 6 days and 5 hours to go, we’re practically half way there!!”. And that was what it was like. 

Some nights I was called back to the ward so often I gave up getting changed and went to the ward in my pyjamas. Nobody seemed to notice. Many nights I couldn’t leave the emergency department as I tried to help staff calm down violent patients. Most nights there was no room for admission to the psych ward so I admitted them to the 'Rad ward' which was the radiology department that closed at 5pm. The patients laid in temporary beds. We are talking about 2005 not 1925. Many days I had no sleep and was expected to drive to Echuca to start clinic at 9am the next day. Not conducive to good learning, not conducive to me or my patients. But the way it was. These walls would know I went to the lake here in Bendigo one day, called my best friend, told her I was quitting and drove home. I did go back on Monday but gee it was on a knife edge.

So here I am, in this most salubrious hotel, uber chic, and the total opposite of what I was given while up here as a doctor. No lino on the floors, no rats, no shared bathrooms with cold water. In fact truth be told I begged to stay here in the nurse’s accommodation as psychiatry registrars were placed in old houses on the outskirts of Bendigo and we were too frightened to travel back and forth overnight in our cars to the ward. We begged to live within the derelict nurses accommodation because there was security on site and we could walk to the ward. 

I am stronger than ever to write my book because despite how totally awful it can be at times to be a doctor in training, we do get through and life gets better. Recently, a psychiatrist contacted me out of the blue. She was a registrar I coached during her training and she rang to tell me she gained her fellowship with the RANZCP. She was so grateful. The one thing she remembered me saying and that kept her going probably on nights when she was pyjama clad, sleep deprived and slave to her pager was I told her just get thought your training and it will get better. They were her words to me, yes, Helen, just like you said it did get better....

And as I finish my book in this place of 360 degrees growth and experience, 10 years later, I also know like I never believed back then, it does get better. 

Feeling connected

Doctors are extremely busy people. So are many professionals. We go about our day attending to our patients, reduce our ever increasing pile of administration, run our practices and juggle our personal lives. When our patients need us in an emergency they have no idea there may be quite a few with similar needs on the same day. And nor should they. We are quite skilled at triaging, attending to the problems at hand and delivering as much as needed for our patients. But there does come a time when we would like to raise the white flag and say, STOP! Just for a minute, so we have a chance to breathe and an opportunity to recharge.

I have taken myself away for a weekend of solitude and reflection, a moment to take stock and assess where I currently am in my career and where I am heading. Giving my all, as doctors do, can lead to needs to escape and energise. And so here I am in a coastal location, remembering who I am and what is important to me. 

This is no new revelation. Doctor’s mental health and wellbeing relies on the notion that we all need a break, we all need to listen to our bodies and minds, and pro-actively manage our needs for our own health and the health of the patients we are responsible for. So, why do we find it hard to get away?

Part of it is the realisation that at the end of the day, many of us are small business owners, managing staff, and scrutinising cash flow. We are not only responsible for our patients but also for our staff and our obligations under tax law. We work to pay our college fees, medical indemnity and other professional liabilities we incur as doctors. We juggle our time amongst our clinical duties and our business requirements. We can, quite easily, forget that we are like other doctors, feel isolated and overwhelmed, and before we know it, consumed by worry and insecurity.

Medical training does not equip us with business skills, yet many of us are small business owners. At times I truly believe that learning all the branches of the facial nerve was inconsequential when compared to learning how to pay the BAS on time or service overdrafts. But this is real life post fellowship. The answer? Becoming and staying connected to your peers, and asking and receiving help.

The RANZCP strongly advises we form peer review groups post training in order to discuss clinical cases and obtain feedback and support. Obviously very important but way too narrow for most of us in private practice. In my time since fellowship I have forged and cherished some very strong relationships with peers that have nothing to do with discussing complex cases of schizophrenia, or the latest views on using antidepressants in bipolar depression. As a small business owner and sole director, my most valuable mentors are those who have done it before me, who are honest enough to admit their mistakes and can tell it like it really is. They have helped me understand how to run a practice in ways my training did not prepare me for.

And now, through social media I feel connected to other health professionals including doctors who have similar creative pursuits to mine. I have discovered a group of doctors who have a passion for writing, as do I. Now that registrar days are over I have pursued other areas of learning that matter to me. This has transpired into a feeling of connectedness, contribution to a community, asking for help and truly learning. 

As I embark upon my weekend of solitude and throw myself into finishing my first novel, I thank those who I have met and who have supported me to learn how to take a break, how to follow my passions, and how to actually make it happen. You know who you are. See you when I get back to reality.

If a doctor's practice ran the way Dutton is running health..

Boy, has it been a turbulent time in health lately. And for all the wrong reasons. Yet the federal government plough on, resisting communication or negotiation while they stick to their mantra – their proposed changes for health and necessary for the good of the country.

I keep trying to define what can be good for patients in all of this, but can only see a trail of negativity, a loss of services and values in healthcare for patients and fears of a diminishing medical workforce if education and health cuts are passed.

Then I thought about another way. Try for one or two minutes, just try to see the government’s point of view. Really, really try, maybe not be so ‘pessimistic’. Maybe see if it would make sense if I try and apply Dutton’s principles to a busy medical practice and see if these policies have any merit. Or are they simply something to apply on a grand scale rather than in a practical situation?

So, here’s my take on applying these changes to a real world setting;, what doctors and I work in every day,

A new world scenario for a busy medical practice:

Imagine this for a while and see how it fits. Doctors in this busy private practice hold a meeting behind the staff’s back and announce in unison that the situation at the practice is worse than anybody imagined. They have had some external auditors in and had no idea things were this bad when they signed the lease.

The principal doctors announce that due to the crisis left by previous tenants, there will no longer be a tea room, toilet facilities or any basic staff amenities. The principal doctors agree these measures will be tough but necessary. They did not appreciate how the previous tenants had left the premise. Hence they cannot be held accountable for what would be tough but fair changes for all.

The principal doctors inform the staff that there will be a 30% reduction in staffing commencing in 2 weeks. As a gesture of goodwill, the principal doctors will take a 2% pay cut, because, after all ‘we’ve ALL inherited this MESS’. There will be limited access to services such as Medicare or the Australian Tax Office. They were just superfluous services anyway, not really required by a busy medical practice.

Beginning in a week’s time, cash registers will be installed at reception and all staff will instruct patients to pay up before they have any chance of seeing a doctor. Even if presenting with chest pain, acute shortness of breath or other life threatening symptoms. The doctors understand that there will be ‘casualties’ due to this blanket measure but nevertheless it will work for the good of most who need health care. And it’s important for practice staff to remind patients that each and every dollar raised will go to curing their health problems via a medical research fund, so they will no longer experience chest pain or shortness of breath in the future. After all, the new breed doctors know, there is nothing in this ‘acute health care’ it costs too much and there is no return on investment.

The doctors warn the practice staff that this will be a very difficult time, but to remind patients that it is difficult for all, not just those who have recently lost their job,  have a mental illness, perhaps a physical disability or find themselves homeless of late. TOUGH. FOR. ALL. In fact, the principal doctors announce they will spend $250,000 to rebrand the practice with this telling and sage message. Staff will wear this logo on their new uniforms and doctors will add it to the business cards. Everybody will assume their rightful role in where they now fit in the practice and the greater community.  At the bottom.

When doctors finally get to see their patients, suddenly stricken with low self esteem and self worth, they will turn off their listening ears and preach to their heart’s content. They will fail to miss the tidal wave of patients surging the wrong way out of the practice door (or perhaps the right way), there will be serenity in the waiting room, but no place for reflection.

At least these radical but necessary changes will only need to be in place for three years. After that the practice lease will be up for renewal, and the new team of doctors can inherit the mess, seeing fit to do with it what they want.

Imagine this in the real world? What doctor would stand for this on behalf of their patients or their own professional lives?

Thoughts?

The dominoes are starting to tumble

A few weeks out from the State budget and one week out from a Federal Budget, we are beginning to see the direct effects of winding back health care for all, but especially for those with mental illness.

Yesterday The Age in Melbourne reported the State Government would no longer fund St Mary’s house of welcome in Fitzroy, as well as many other institutions that genuinely support and care for those with severe mental illness.  

I remember St Mary’s house of welcome from my training days. Back then it was a bustling place, a care and respite space for many inner urban patients with a mental illness. It provided a community, a haven, hot meals, clothing, shelter and love. Nowadays, it is even busier, and would have been full to the brim for years to come had it not received the news it would no longer receive government funding the day after the state government budget was delivered.

Many of the patients we knew within our service would feel safe going to St Mary’s when unwell, rather than calling a crisis team or attending an emergency department. In fact, most patients experiencing a relapse of severe mental illness avoid psychiatric services. St Mary’s provided a bridge between patient and service, our service could be alerted by their staff if somebody was unwell. They would do this in discreet and compassionate way, and would discourage psychiatric services from attending at St Mary’s to keep it as a safe place. However, services could follow up after hours and ensure treatment was provided.

There is no doubt that such wonderful facilities never come to the attention of politicians except as a cost on a piece of paper, to be cut when needed. There is no human element to the decision making. Where will these people go as these services break down? What will happen to their mental health? And if they can’t afford meals how will they afford to pay their GP’s $7.00?

Little is known about taking payments from patients in public hospitals. This seems to have been pushed to the State Government’s discretion. Will an acutely mentally unwell patient lost from services be asked to pay? Even when extremely paranoid and actively avoiding services? What is the point of newer medications and modalities of care if we are actively discouraging patients from seeking help, by taking away their places of refuge and charging them for care that they have no insight they need.

What will be the next domino to fall?

Choosing to play 'win-lose' in negotiation and how it applies to #budget2014

Greetings all,

As promised, here is another key learning from my WMA caring physicians of the world conference at INSEAD this month.

During a very busy timetable we immersed ourselves in understanding negotiation skills and multi party coalitions. The same day, I watched the Commission of Audit report and discussions fill twitter feeds. I could see what was happening, the Federal Government’s strategy behind #budget2014 was clearly win-lose negotiation tactics, where the tool of choice is power not communication.

When a party or individual chooses to play win lose, they use their power to influence and win. They need to be very aware of the risk and believe the reward will be great enough to set off the risks. Win lose negotiations fall down when such parties overestimate reward and underestimate resistance.

So what does this mean in the context of the last few days? Well, choosing to deliver a budget that is harsh, hits the most vulnerable that a society should protect, doesn't contain a lot of information about how these measures could even be implemented, and then states that it will help Australia out of a perceived economic mess, may be overestimating reward.

I don't see reward when it comes to the $7.00 copayment. I have spoken to a patient who takes warfarin, who told me that if the copayment for pathology services go through, they will take their chances rather than have twice weekly blood tests. 

As a psychiatrist, I may no longer be able to prescribe lithium as often, a fantastic medication for bipolar disorders, as lithium monitoring is crucial with weekly blood tests needed to avoid kidney and thyroid disturbance. The ridiculous aside to this is that lithium is much cheaper than newer atypical agents and more cost effective for government. But, if my patient doesn't return, doesn't have regular monitoring, and develops renal dysfunction, they will then be knocking on the bulging doors of the emergency department. For the sake of making a GP or pathology centre claim $7.00 from a patient, because, after all, they have lost $5.00 per consult, costs and burden of disease will only but rise.

What will we see playing out in the next few days? Parties that choose win-lose and underestimate resistance will feel they have won for a little while until key stake holders form coalitions and lobby to block changes. Key stakeholders that have been shut out of any discussion about this most important budget, and all important patient groups will lobby via all channels available. Let's see what win-lose really looks like in a few weeks, and at the next election.

Then, a word of advice for all, using 'win-win' in negotiation requires communication. How about Government communicate with RACGP, GPRA, AMA,  and  include doctors rather than just rule them, or reduce them to workers of another branch of the ATO.

Thoughts?

Helen